CORE TOPICS IN PERIOPERATIVE MEDICINE CORE TOPICS IN PERIOPERATIVE MEDICINE by Jonathan Hudsmith BM FRCA Department of Anaesthesia Peterborough Hospitals NHS Trust Dan Wheeler MA BM BCh MRCP FRCA Clinical Lecturer in Anaesthesia University of Cambridge Arun Gupta MA MBBS FRCA Director of Postgraduate Medical Education University of Cambridge London ♦ San Francisco cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru, UK First published in print format isbn-13 978-1-841-10139-2 isbn-13 978-0-511-16584-9 © Greenwich Medical Media Limited 2004 2004 Information on this title: www.cambrid g e.or g /9781841101392 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. isbn-10 0-511-16584-6 isbn-10 1-841-10139-7 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org p a p erback eBook (NetLibrary) eBook (NetLibrary) p a p erback Contents Preface vii Contributors ix 1.Perioperative management of cardiovascular disease 1 John McNamara 2.Perioperative management of respiratory disease 13 Tim Clarke 3.Perioperative care of children 19 Warren Fisher 4.Perioperative management of the obese patient 25 Anand Sardesai 5.Perioperative management of the elderly patient 33 Karen Pedersen 6.Perioperative management of emergency surgery 43 Jeremy Lermitte and Jonathan Hudsmith 7.Perioperative fluid management 55 Iain MacKenzie 8.Perioperative management of coagulation 65 Andy Johnston 9.Perioperative management of steroid therapy 73 Fraz Mir and Michael Lindop 10.Perioperative management of endocrine disease 79 Dan Wheeler and Ingrid Wilkins 11.Perioperative management of diabetes 91 Mike Masding and Wendy Gatling 12.Causes and treatment of aspiration 99 Paul Hughes 13.Transfusion and blood products 105 Andy Johnston 14.The critically ill patient 111 Vilas Navapurkar 15.Inotropes 121 Andy Gregg 16.Arterial blood gases 127 Simon Fletcher 17.Drugs used in anaesthesia and sedation 137 Mike Palmer 18.Local anaesthetics 145 Sue Abdy 19.Monitoring used in the perioperative period 153 Ian Bridgland and Katrina Williams 20.Deep vein thrombosis and thrombo-embolic disease prophylaxis 165 Jonathan Hudsmith 21.Postoperative nausea and vomiting 173 Pete Young 22.The management of perioperative pain 179 Parameswaran Pillai and Richard Neal 23.High dependency and recovery units 191 Helen Smith 24.Postoperative hypoxia 199 Mark Abrahams 25.Postoperative hypotension 207 Chris Sharpe 26.Postoperative complications 213 Dan Wheeler and Jeremy Lermitte 27.Perioperative scenarios 237 Dan Wheeler and Parameswaran Pillai 28.Multiple choice questions 257 Quentin Milner Index 277 Contents vi Preface Undergraduate medical education is continuously changing to meet the requirements for the training of future medical practitioners. Over the last few years the concept of perioperative medicine has evolved encompassing the preoperative assessment and optimisation of patients, the intraoperative and postoperative management of these patients and importantly the recognition, diagnosis and treatment of the critically ill patient. The relevance of this to undergraduate medical students is undeniable and a number of medical schools have now incorporated a module of Perioperative Medicine into their curricula for medical students. The aims of this book are to provide concise, informative chapters on many aspects of perioperative medicine, allowing medical students to bridge the gap between their clinical attachment in this specialty, first year house officer jobs and preparation for postgraduate examinations. We make no apology for repeating important messages and subsequently there may be some crossover of subject matter between chapters. Changes to the structure of Senior House Officer training will result in incorporation of a Foundation year for the majority of newly qualified doctors. This book covers many of the situations and problems that these doctors will have to face. By providing a broad overview of the perioperative period, this text can be a very useful quick reference guide. Effectively caring for patients in the perioperative period is a complex and demanding job. Doctors and nurses need to be able to detect early signs of any problems during this time, so that interventions can be planned to optimise outcome for their patients. This book should help staff achieve this goal. This book will also be useful to those preparing for Surgical, Anaesthetic and Accident and Emergency postgraduate examinations. Nurses and other healthcare professionals, who are taking on increasing clinical responsibilities within the perioperative period, will also find this book invaluable. Jonathan Hudsmith Dan Wheeler Arun Gupta August 2003 Contributors Sue Abdy MBBS DRCOG FRCA Department of Anaesthesia Queen Elizabeth Hospital, King’s Lynn Mark Abrahams MBChB DA FRCA Department of Anaesthesia Norfolk & Norwich University Hospital NHS Trust Ian Bridgland MBBS MSc DRCOG FRCA FANZCA Department of Anaesthesia St. Vincent’s Hospital, Sydney, Australia Tim Clarke MBChB FRCA Department of Anaesthesia Blackburn Royal Infirmary Warren Fisher MBChB FRCA Department of Anaesthesia Royal Berkshire Hospital, Reading Simon Fletcher MBBS FRCA Department of Anaesthesia Norfolk & Norwich University Hospital NHS Trust Wendy Gatling MBChB DM FRCP Department of Medicine & Diabetes Centre Poole Hospital NHS Trust Andy Gregg BM MRCP FRCA Neurocritical Care Unit Addenbrooke’s NHS Trust, Cambridge Arun Gupta MA MBBS FRCA Director of Postgraduate Medical Education University of Cambridge [...]... history, examination and investigations 2 Cardiac risk and surgery 4 Cardiac risk and anaesthesia 4 Ischaemic heart disease and angina 6 Hypertension 7 Cardiac failure 7 Cardiac dysrhythmias 7 Valvular heart disease 8 Pacemakers 8 1 Core topics in perioperative medicine Introduction 1 Cardiovascular disease is common in the surgical population, occurring in at least 10% of patients presenting for surgery... Guideline Update Perioperative Cardiovascular Evaluation for Non-cardiac Surgery A Report of American College of Cardiology/American Heart Association Task Force on Practice Guidelines, November 2002 11 2 Perioperative management of respiratory disease Tim Clarke Common diseases 14 History 14 Examination and investigations 15 13 Core topics in perioperative medicine 2 Respiratory disease is common in. .. The history and examination should guide investigations in children and while there may be little place for the routine blood tests that are taken in Perioperative care of children adults, appropriate investigations are mandatory where there is a good indication In some cases, where blood sampling is known to be difficult, it is worthwhile discussing the investigations with senior clinicians It may be... period Administer supplemental oxygen, which should be humidified if possible to prevent secretions from desiccating When administering oxygen 17 Core topics in perioperative medicine 2 to patients with type II respiratory failure it is wise to use a fixed performance facemask, i.e one that delivers a fixed concentration of oxygen irrespective of the patient’s breathing pattern Major abdominal or thoracic... – raised bicarbonate may indicate chronic CO2 retention When recording arterial blood gases, always remember to note down the concentration of oxygen that the patient was breathing at the time (air ϭ 21% oxygen) Respiratory failure is defined as an arterial Pao2 of 8.0 kPa or less when breathing air It is divided into type I and type II 15 Core topics in perioperative medicine Type I respiratory failure... months → 30% 3–6 months → 15% Ͼ6 months → 6% This may be significantly reduced with perioperative intensive care Recent research has suggested that the perioperative risk of MI is not as high as previously thought The risk after a previous infarction is related 5 Core topics in perioperative medicine 1 less to the age of the infarction than to the functional status of the ventricles and the amount of myocardium... within 6 weeks of infarction as a time of high risk for a perioperative cardiac event (6 weeks ϭ mean healing time of the infarct related lesion) The period from 6 weeks to 3 months is of intermediate risk In uncomplicated cases, there appears to be no benefit in delaying surgery more than 3 months after a MI This is in contrast to the research of the 1980s The important questions to ask when seeing... Anaesthesia 1988; 43(7): 543–551 18 3 Perioperative care of children Warren Fisher Introduction 20 Preoperative preparation 20 Assessment 20 Common problems 21 Postoperative care of children 23 19 Core topics in perioperative medicine Introduction Children present a range of problems for their carers They present in a range of ages, a range of sizes and with a range of clinical conditions greatly different... Prostate surgery 4 *Combined incidence of cardiac death and non-fatal myocardial infarction † Further preoperative cardiac testing is not generally required Perioperative management of cardiovascular disease Table 1.3 Goldman cardiac risk index Finding Score Evidence of uncontrolled cardiac failure, e.g third heart sound, elevated jugulovenous pressure 11 Myocardial infarction within 6 months 10 Ventricular... should stop smoking Nicotine is an adrenergic agonist which increases blood pressure, increases myocardial oxygen demand and may reduce coronary blood flow Carbon monoxide in cigarette smoke combines avidly with haemoglobin to form carboxyhaemoglobin, which cannot carry oxygen These effects are reduced after 12–24 h abstinence Cigarette smoke also reduces ciliary and immunological function in the lungs . CORE TOPICS IN PERIOPERATIVE MEDICINE CORE TOPICS IN PERIOPERATIVE MEDICINE by Jonathan Hudsmith BM FRCA Department. Michael Lindop 10 .Perioperative management of endocrine disease 79 Dan Wheeler and Ingrid Wilkins 11 .Perioperative management of diabetes 91 Mike Masding and